People with HIV and hepatitis C co-infection were
significantly more likely to experience organ rejection than people with
C alone or HIV alone after undergoing a liver transplant, according to a
of 11 years' experience of liver transplantation in people with HIV and
with hepatitis C virus (HCV) in the United States, published in advance
online in the journal Clinical Infectious Diseases.
The study investigators say that their findings underline
the importance of treating hepatitis C either before or immediately after liver
transplantation in order to improve outcomes, rather than assuming that
people with co-infection will have poorer outcomes based on historical data.
Liver transplantation remains a relatively rare procedure
among people living with HIV, due in part to concerns about poorer
higher rates of organ rejection in people with HIV. Although a study
out by the United States National Institutes of Health (NIH) showed a
lower rate of survival three years after transplantation and a higher
organ rejection in people with HIV and hepatitis C co-infection compared
to people with hepatitis C alone (mono-infection), the majority of
transplants in each group was successful.
The success of transplantation in people with HIV who are not do not
have hepatitis C co-infection has been unclear. Furthermore, data are
lacking outside the clinical trial
setting regarding the outcomes of transplants in people with
at transplant centres which did not take part in the NIH trial.
Liver transplantation in people with hepatitis C is further
complicated by the high risk of hepatitis C recurrence and subsequent rapid
progression of fibrosis after transplant, in the absence of highly effective
treatment. Although more effective treatment is now becoming available that may
cure hepatitis C in over 90% of people, before or after liver transplantation,
liver transplant is likely to continue to be necessary in people with end-stage
liver disease – and hepatitis C is not the only cause of end-stage liver
disease in people living with HIV.
Researchers at the University of Pennsylvania reviewed all
liver transplants carried out in the United States between February 2002 and
December 2013 – a total of 43,987 transplant recipients with information on HIV
and HCV serostatus. Of these people, 20,829 had HCV, 72 had HIV and 160
were had HIV and HCV co-infection. A total of 22,926 people without HCV or HIV
formed a reference group of transplant recipients.
African Americans were significantly more likely to be
represented in the HIV and HIV/HCV co-infection group (P<0.001), while people
with HIV were younger than the transplant recipients with HCV mono-infection or those in
the reference group.
People with hepatitis C or HIV had significantly worse liver
damage as measured by MELD score, and people with HIV were significantly more
likely to have moderate to severe impairment of overall physical function than
other groups (p < 0.001).
The study found that one- and three-year survival was lowest
in the group with co-infection (75% and 47%) compared to the reference group (89% and
76%). One-year survival was similar to the reference group in the HIV and the
HCV mono-infection groups, but three-year survival was lower (66% and 67%
respectively). Infections caused death more frequently in people with HIV and
people with co-infection.
Organ rejection and graft loss was significantly more common
in the group with co-infection (44.8%) compared to the reference group (23.6%), and was
also more frequent in transplant recipients with mono-infection (30.6% in people with HCV and
31.4% in people with HIV).
Univariable analysis found that HIV mono-infection was not
associated with a significantly increased risk of death or organ
whereas HCV mono-infection and HIV/HCV co-infection were (1.46 [95%
confidence interval 1.41-1.52] and 2.62 [95% CI 2.06-3.33) respectively.
Hepatitis C mono-infection and HIV/HCV co-infection were similarly
with transplant rejection whereas HIV was not associated with rejection.
The authors conclude that any excess post-transplant risk
for people with co-infection is related to hepatitis C, underlining the importance of
treating the infection.
The study authors say that their findings “argue for
treatment of HCV infection either in the pre-transplant setting or immediately
post-transplant.” They argue that availability of new interferon-free
combinations of direct-acting antivirals makes this feasible. Alternatively,
they suggest, organs from donors with HCV could be transplanted for
people with mono-infection and co-infection, with hepatitis C treatment after
transplant. This option would broaden the donor pool, they suggest, making it
more likely that people with hepatitis C with end-stage liver disease would
receive the liver transplant they need.